Ventilate and Intubate But Don’t Forget Communicate

Failure to communicate, and making assumptions rather seeking true facts,  can endanger your patient. Many years ago I was participating in a volunteer medical mission to Kenya when I learned a valuable lesson in communication which I often share with my students. In this case, multiple providers made bad assumptions about what the others knew that led to a potentially dangerous situation involving intubation.

The Case

The child on the OR table in Kenya during our volunteer medical mission was about 3 years old and scheduled for cleft lip repair. Dr Y, the anesthesiologist, was still mask ventilating the patient when he called me for help. I was anesthesia team leader and it was my job to prepare the patients as well as help everyone else.

During the process of getting ready to intubate this particular child he found he could not open the boy’s mouth. Malignant Hyperthermia, a severe reaction to certain anesthetics, can present with trismus or jaw rigidity, so we were worried.

As we were checking for other signs of rigidity and the boys temperature, the surgeon joined us. “You won’t be able to open his mouth,” he said.  “He had an infection when he was one year old and his jaw is frozen shut. I’m going to fix that before I repair the lip.” He paused as he saw us silently staring at him. “It’s in his chart,” he said defensively.

Dr Y. looked sheepish and replied, “ I didn’t read his chart. I saw that you had signed off on it and figured if there was a problem you’d have told me.”

Because we were a small team with the goal of operating on 100 patients in 5 days, I had made the command decision to have our physician’s assistant help with preop exams. I glanced at the chart. Sure enough, buried in the physician assistant’s note about a normal healthy little boy with a cleft lip was a short comment about his frozen jaw. I had countersigned the note.

I had failed to teach the P.A. the signs of difficult intubation, so she didn’t know that it was important to tell me. I had been too preoccupied to read the note in detail past the words healthy child. I hadn’t personally examined all 100 children. My colleague had been too focused on getting the case started.

“What’s the problem, just intubate him?” asked our surgeon, who clearly didn’t realize he should have told us about the frozen jaw.

I examined the child. A locked jaw is not a common problem in the US — rapid medical care prevents it from developing. Children in the third world lack access to medical care and may have to live with such a disability for the rest of their lives. Smaller than normal peers, children with frozen jaws often have short, poorly developed mandibles. This child looked like he had Pierre Robbin, a congenital syndrome associated with a much smaller than normal jaw.

I lubricated a small nasal airway with local anesthetic ointment. Attaching the adaptor from an appropriately sized endotracheal tube, I slid it into the boy’s left nostril and hooked up our anesthesia breathing circuit. The child could continue to breathe the anesthesia gas spontaneously through the nasal airway, allowing us to nasally intubate through the other nostril while he was still asleep. The surgeon did the surgery, and the child recovered.

This is a very useful technique that I have often used during blind nasal intubations, or other difficult intubations when keeping the patient asleep but breathing spontaneously. I wrote about it here. :

Lessons learned:

  1. Communicate. Never assume your teammates, no matter how talented or highly educated, know what you consider important — or that they will remember to tell you.
  2. Never skip a safety step, regardless of how “easy” or “safe” the case seems.  No intubation is easy, and all involve some risk. My Dad was a commercial airline pilot. He always tells me that the more difficult approaches are often also the safest.  In a difficult approach, everyone in the cockpit is intently focused, and distractions are not tolerated, because the crew knows the landing is not easy.  In contrast, an easy landing approach invites overconfidence and distraction, which can lead to disaster.
  3. Always have a plan B and the necessary equipment to carry it out.

We are all skilled at our jobs and attentive to our patients. Sometimes it’s the communication that trips us up.

May The Force Be With You

Christine Whitten

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